"Infectious disease which antedated the emergence of humankind will last as long as humanity itself, and will surely remain, as it has been hitherto, one of the fundamental parameters and determinants of human history."
– William H. McNeill
For the last five weeks, like many others, I have been working from home, living under massive restrictions imposed to "flatten the curve" of Covid-19—which has become the public health mantra for many countries. A lot has been written about this new pandemic, how and where it originated, how quickly it spread across continents, the complex international health diplomacy, if a blanket decision about lockdown was required, etc. The significant impact of this pandemic on the economy is not unknown to us. Financial schemes have been declared by many countries to minimise the damage.
Seeing everyday headlines, it seems the discussion is heavily tilted towards the economic slowdown (some are comparing it to the Great Depression that lasted from 1929 to 1939), how helpful the financial schemes are, the steps that governments should embrace to prepare and respond to the different scenarios emerging from the Covid-19 crisis. But the fragile healthcare systems in many countries, including the industrialised countries, health policies that are not evidence-based, multiple underlying inequalities in healthcare services—these issues are not making as many headlines as the economic concerns. Above all, there is a lack of discussion on what we have learned from our prior experiences. We may not get all the answers from past epidemics as every disease is unique, but many countries have failed to learn from past outbreaks in strengthening their defences to respond to emergencies. Let us take stock of some examples.
As public health students, we learned that the eradication of small pox was a landmark achievement in the history of public health. We successfully eradicated small pox at a time of weak healthcare systems in many countries and at a time of famine and people fleeing civil wars. This extraordinary achievement was possible due to many factors, such as strong surveillance (paper-based) and containment, nations working together towards a common goal and, of course, mass vaccination. Dr Halfden Mahler, Director General of WHO at the time of small pox, described the eradication programme as an outstanding example of management, not of medicine. At the height of the Cold War, the United States of America and the former Soviet Union worked together to eradicate small pox. However, the lack of international collaboration and coordination at the time of Covid-19 is quite glaring.
Instead of taking calm and balanced approaches, nations are busy blaming each other. Countries are battling for Personal Protective Equipment (PPE), which has fuelled price increases and created a frenzy in the market. As we all are working for a common cause, it is time to take a cue from the small-pox eradication programme on international solidarity despite existing ideological and geopolitical differences.
There is no alternative to a strong and effective surveillance system in controlling communicable diseases. The outbreak of Severe Acute Respiratory Syndrome (SARS), first noted in November 2002, was contained by July 2003 by non-pharmaceutical interventions. Strong surveillance, isolating people, rigorous contact tracing, screening passengers at airports returning from affected countries—all helped to contain the outbreak. Taiwan was on alert due to their experience in SARS. They were quick to control borders, scale up surveillance and implement contact tracing which contributed to their low number of Covid-19 cases despite their proximity to the original epicentre (in China). Taiwan successfully used technology for contact tracing. The proliferation of mobile phones has given us an opportunity to track cases and trace contacts more effectively. This has made tracking certain services, such as ante-natal care, pre-natal care and expanded programmes of immunisation, possible. We perhaps need to explore how else technology can be effectively used for preventive care, diagnostics, therapeutics and comprehensive disease management. Needless to say, the utilisation of technology should be carried out ethically, with caution and only for health purposes.
The fundamental criteria of managing any outbreak are the timeliness of detection, completeness of reporting and laboratory capabilities. The experience of controlling the Middle East Respiratory Syndrome (MERS) helped South Korea in flattening the Covid-19 curve. They learned it the hard way—that laboratory testing is essential in controlling infectious diseases. We are yet to see if South Korea can sustain this success because there are still many uncertainties about Covid-19. Unfortunately, not many countries have learned from their experience with SARS or MERS. They were completely unprepared for this current pandemic and did not invest enough in their health systems, despite the fact that there had been warnings about communicable disease outbreaks. Countries did not wake up even after the severe Ebola outbreak from 2013 to 2016.
As long as international trade and the movement of people in different continents exist, the risk of disease outbreaks will remain. If we do not buckle down now, future epidemics will have a severe impact on our health systems and on our economy. We need to recognise the need for a strong healthcare system to counter future challenges. Kerala, a state in southwest India, known as "God's own country", is a shining example of flattening the Covid-19 infection curve. Their investment in public health over many years, improvement in human resources and health system infrastructure helped the state government to handle the outbreak effectively. The experience in controlling Nipah virus in 2018 ensured an effective approach to controlling the novel coronavirus crisis.
Unfortunately, the shining examples are few and far between. It is time to move away from the health vs. economy discussion—both are, after all, interlinked. There is no other alternative than scaling up financial resources for health, building and equipping facilities, ensuring adequate staffing and effective surveillance. Every day we are reading about the lack of healthcare professionals, ill-equipped hospitals and laboratories and weak surveillance systems. Responses to the threats of infectious diseases should be high on the policymakers' agenda. A robust public healthcare system is essential to weather future outbreaks. It will be difficult to close our eyes after realising the economic and human costs of a pandemic.
Recently, I saw a quote in one of WhatsApp messages. It says, "you cannot change the wind, you can adjust your sails". Pandemics will occur in the future and with greater intensity. It is time to adjust our health system. We have the necessary experience, scientific knowledge and technology to prepare better.